DCA95MA054

NTSB accident investigation · Embraer EMB-120RT · Carrollton, GA · August 21, 1995

Accident · FatalClass 1 · MajorFinal report
Date
August 21, 1995, 12:53 local (16:53 UTC)
Place
Carrollton, GA
Injuries
8 fatal, 13 serious, 8 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N256ASEmbraer EMB-120RT
Weather
Visual (VMC) · Day
Status
Completed · report December 15, 1997
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19950821024859A
Case key
10997

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the in-flight fatigue fracture and separation of a propeller blade resulting in distortion of the left engine nacelle, causing excessive drag, loss of wing lift, and reduced directional control of the airplane. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered by Hamilton Standard because of inadequate and ineffective corporate inspection and repair techniques, training, documentation, and communications. Contributing to the accident was Hamilton Standard's and FAA's failure to require recurrent on-wing ultrasonic inspections of the affected propellers. Contributing to the severity of the accident was the overcast cloud ceiling at the accident site.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Propeller failure/malfunctionClimb
Propeller system/accessories,blade - corrodedCause
Propeller system/accessories,blade - fatigueCause
Maintenance,overhaul - inadequateManufacturerCause
Procedure inadequateManufacturerCause
Insufficient standards/requirements,aircraftFaa(organization)Factor
Inadequate trainingManufacturerCause
Information insufficientManufacturerCause
Propeller system/accessories,blade - separationCause
Forced landingEmergency descent/landing
In flight collision with objectEmergency landing
Weather condition - low ceilingFactor
Object - tree(s)

Analysis

Atlantic Southeast Airline Flight 529 was climbing through 18,000', when a blade from the left propeller separated. This resulted in distortion of the left engine nacelle, excessive drag, loss of wing lift, & reduced directional control. The degraded performance resulted in a forced landing. While landing, the airplane passed through trees, impacted the ground, & was further damaged by postimpact fire. An exam of the left propeller revealed the blade had failed due to a fatigue crack that originated from multiple corrosion pits in the taper bore surface of the blade spar. The crack had propagated toward the outside of the blade & around both sides of the taper bore. Due to 2 previous blade failures (separations), a borescope inspection procedure had been developed by Hamilton Standard to inspect returned blades (that had rejectable ultrasonic indications) for evidence of cracks, pits & corrosion. The accident blade was one of 490 rejected blades that had been sent to Hamilton Standard for further evaluation & possible repair. Maintenance technicians, who inspected the blade, lacked proper NDI familiarization training & specific equipment to identify the corrosion that resulted in fatigue. (See: NTSB/AAR-96/06 for additional information.)

Factual narrative

Please See NTSB Bluecover Report of Aircraft Accident - NTSB AAR-96/06 for further information regarding this accident.

Aircraft

Registration
N256AS
Reported as
Embraer EMB-120RT
Category
Airplane
Serial number
120122
Airframe hours
17,151
Engine
P&W PT118, 1,800 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
Atlantic Southeast Airlines, doing business as Delta Connector
Registered owner
Atlantic Southeast Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 20, 1995
Departed
ATL · Hartsfield Int., GA
Destination
GPT · Gulfport, MS
Flight plan
IFR
Airport
CTJ · West Georgia Regional, runway 34, 5,001 × 100 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
9,876 total · 7,374 in this make and model · 212 in the last 90 days · 67 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 6 knots
Visibility
10 statute miles
Lowest ceiling
800 ft overcast
Temperature
75 °F, dew point 75 °F
Altimeter
30.00 inHg
Observed at
CTJ, 4 nm away

Docket · 106

The files NTSB released with the investigation on January 16, 1996, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Operations 2A - Factual Report of Group ChairmanItem 1 · .PDF · 4.5 MBOperations 2B - AttachmentsItem 2 · .PDF · 52.9 MBATC 3A - Factual Report of Group ChairmanItem 3 · .PDFATC 3A - Addendum to Group Chairman's Factual Report (Transcripts)Item 4 · .PDF · 2.0 MBMeteorology 5A - Factual Report of Group ChairmanItem 5 · .PDF · 514 KBMeteorology 5B - Factual Report of Group Chairman, Attachment 1Item 6 · .PDF · 107 KBMeteorology 5C - Factual Report of Group Chairman, Attachments 2-9Item 7 · .PDF · 13.2 MBSurvival Factors 6A - Factual Report of Group Chairman (added 3/11/96)Item 8 · .PDF · 272 KBStructures 7A - Factual Report of Group ChairmanItem 9 · .PDF · 358 KBStructures 7A - Photo 01. Aerial view of accident site, looking northwest , with main wreckage in background. Arrows denote left wing/engine ("LW") and left propeller assembly ("P").Item 10 · .PDF · 49 KBStructures 7A - Photo 02. Ground view of final tree impacts, looking west/southwest. Note the tree swath angled down from left to right.Item 11 · .PDF · 37 KBStructures 7A - Photo 03. Aerial view of main wreckage.Item 12 · .PDF · 57 KBStructures 7A - Photo 04. Left engine and inboard section of left wing.Item 13 · .PDF · 41 KBStructures 7A - Photo 05. Inward, upward crushing to left side of forward fuselage.Item 14 · .PDF · 63 KBStructures 7A - Photo 06. top view of empennage.Item 15 · .PDF · 33 KBStructures 7A - Photo 07. Right fuselage, engine, and wing.Item 16 · .PDF · 44 KBStructures 7A - Photo 08. Reassembled left wing leading edge outboard of left engine. Inboard side abuts outboard side of engine nacelle. Opening in leading edge contains landing light.Item 17 · .PDF · 58 KBStructures 7A - Photo 09. Inboard, aft side of left nacelle skin.Item 18 · .PDF · 47 KBStructures 7A - Photo 10. Damage to middle hinges of left forward cowling doors.Item 19 · .PDF · 48 KBStructures 7A - Photo 11. Frame 1 of left nacelle. Outboard member of frame is deformed aft approximately 90 degrees. Arrows denote location of inboard ("I") and outboard ("O") forward engine mounts (not shown).Item 20 · .PDF · 68 KBStructures 7A - Photo 12. Frame 1 members from left and right nacelles. Arrows denote the torque mount assemblies on the right engine.Item 21 · .PDF · 60 KBStructures 7A - Photo 13. View of front face of forward, inboard engine/gearbox mount bolt (left engine).Item 22 · .PDF · 39 KBStructures 7A - Photo 14. View looking aft of left engine nacelle. Arrows denote aft cowlings ("A"), forward cowlings ("F"), engine air inlet fairing and forward portion of forward cowlings ("FC"), and frame 1 ("1") that werItem 23 · .PDF · 56 KBStructures 7A - Photo 15 & 16. Lower rod ends of the inboard and outboard torque mount assemblies, respectively.Item 24 · .PDF · 29 KBStructures 7A - Photo 17. View looking down at forward, outboard engine/gearbox mount (left engine). Note aft deformation at fracture.Item 25 · .PDF · 28 KBStructures 7A - Photo 18. View looking outboard of forward, outboard engine/gearbox mount bolt (left engine).Item 26 · .PDF · 28 KBStructures 7B - Metallurgist's Factual ReportItem 27 · .PDF · 405 KBStructures 7B - Photo 1. Overall view of the camber side of the inboard piece of the blade.Item 28 · .PDF · 30 KBStructures 7B - Photo 2. Arrow "O" indicates the origin area, arrow "R" indicates a ratchet mark, unlabeled arrowheads indicate fatigue propagation direction, and the dashed lines indicate the extent of the fatigue crack.Item 29 · .PDF · 54 KBStructures 7B - Photo 3. Overall view of the outboard face of the fracture. Arrow "O" indicates the origin area and arrow "R" indicates the ratchet mark. (2X)Item 30 · .PDF · 39 KBStructures 7B - Photo 4. View of the inboard piece of the blade, showing the area of most severe sanding marks on the taper bore surface near the fracture plane. Arrow "S" indicates sealant material. (2X)Item 31 · .PDF · 42 KBStructures 7B - Photo 5. Oblique view of the origin area on the inboard piece of the blade, showing initiation areas ("01" and "02"), lead deposits ("L"), fracture surface damage ("D"), ratchet mark ("R"), and the locationItem 32 · .PDF · 54 KBStructures 7B - Photo 6. Fatigue origin area on the inboard blade piece, with arrows "01" and "02" indicating the fatigue area on each side of the ratchet mark (arrows "R"). Arrowheads on the fracture indicate fatigue propagItem 33 · .PDF · 49 KBStructures 7B - Photo 7. Detailed view of the taper bore surface on the inboard blade piece in the vicinity of origin area "01" (bracket). The ratchet mark is partially visible at the upper left corner of the photograph. (35Item 34 · .PDF · 43 KBStructures 7B - Photo 8. SEM backscatter electron image of the fracture surface in the vicinity of origin area "01" (bracket "01"). The dashed line indicates the extent of heavy oxide deposits. (43.3X)Item 35 · .PDF · 50 KBStructures 7B - Photo 9. Higher magnification view of the mud-cracked appearance of the oxide deposits. (1,750X)Item 36 · .PDF · 34 KBStructures 7B - Figure 10. EDS spectrum from the mud-cracked oxide deposits on the inboard piece of the blade.Item 37 · .PDF · 47 KBStructures 7B - Photo 11. Overall view of the corrosion damage (between arrows "C") associated with origin area "01" (indicated by bracket "01"). Arrow "P" indicates a wide corrosion area also indicated by arrow "P" in figureItem 38 · .PDF · 56 KBStructures 7B - Photo 12. Closer view of the corrosion damage at origin "01". Arrow "X" indicates the point of maximum penetration of the corrosion pitting. Smaller arrows on the fracture indicate crack propagation directionItem 39 · .PDF · 49 KBStructures 7B - Photo 13. Corroded fatigue striation pattern, partially obscured by mud-cracked oxide deposits, near the origin area "01" on the inboard face of the fracture. The arrow indicates the direction of propagation.Item 40 · .PDF · 38 KBStructures 7B - Photo 14. Corrosion pit (white area) at origin "02" on the outboard face of the fracture. Unlabeled arrowheads indicated crack propagation directions away from the origin area. (284X)Item 41 · .PDF · 40 KBStructures 7B - Photo 15. Section "A-A" through fatigue origin area "01" (see figure 11 for location of section). Arrowheads indicate corrosion pits on the fracture. Taper bore surface is to the right. (500X, as-polished)Item 42 · .PDF · 34 KBStructures 7B - Photo 16. Section "A-A" after additional step-polishing, showing a surface corrosion pit (double-headed arrow) and surface ("B") is to the right and the fracture is at the top of the photograph. (400X, as polItem 43 · .PDF · 24 KBPowerplants 8A - Factual Report of Group ChairmanItem 44 · .PDF · 841 KBAddendum A - Powerplant Group Factual ReportItem 45 · .PDF · 1.1 MBAttachment A - Addendum A - Powerplant Factual ReportItem 46 · .PDF · 3.1 MBPhoto 1 Left Engine and Propeller-Propeller and Reduction Gearbox at accident site.Item 47 · .PDF · 48 KBPhoto 2 Left Engine and Propeller-Propeller spinnerItem 48 · .PDF · 62 KBPhoto 3 Left Engine and Propeller-No. 2 propeller bladeItem 49 · .PDF · 48 KBPhoto 4 Left Engine and Propeller-No.1 propeller blade taper bore and pitch change pinItem 50 · .PDF · 32 KBPhoto 5 Left Engine and Propeller-No.3 propeller blade taper bore and pitch change pinItem 51 · .PDF · 38 KBPhoto 6 Left Engine and Propeller-Spinner bulkhead, oil transfer tube, pitch change yoke and piston, and associated hardwareItem 52 · .PDF · 45 KBPhoto 7 Left Engine and Propeller-Turbomachine at accident siteItem 53 · .PDF · 66 KBPhoto 8 Left Engine and Propeller-Turbomachine at accident siteItem 54 · .PDF · 67 KBPhoto 9 Left Engine and Propeller-Main and reduction gearbox magnetic chip detectorsItem 55 · .PDF · 48 KBPhoto 10 Left Engine and Propeller-Low pressure impellerItem 56 · .PDF · 50 KBPhoto 11 Left Engine and Propeller-Low pressure turbine vane ring, upstream sideItem 57 · .PDF · 41 KBPhoto 12 Left Engine and Propeller-High pressure turbine, downstream sideItem 58 · .PDF · 46 KBPhoto 13 Left Engine and Propeller-First stage power turbine vane ring, downstream sideItem 59 · .PDF · 49 KBPhoto 14 Right Engine and Propeller-Engine and propeller in nacelle at accident siteItem 60 · .PDF · 60 KB
All 106 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.